She was just 19, the mother of an infant son. But her husband's drinking binges and the constant criticism from in-laws had undermined her faith in her marriage. So she told the doctor she already had two children. That way, she wouldn't need her husband's signature to obtain a tubectomy.

But now Sumathy is desperate. After last December's tsunami killed her only child in the south Indian coastal town of Mahabalipuram she wants to give birth again. Fearful of the loneliness and social stigma of a childless old age, the fish vendor was among the first of 189 Indian women to accept the Tamil Nadu state government's offer of free re-versals of sterilization.

While officials are striving to provide fresh hope to bereaved parents, it's hardly a simple initiative. The medical uncertainties and social pressures at work in India may give pause to neighboring Sri Lanka, where some sterilized tsunami survivors are just beginning to come forward to request another chance to conceive.

"Wherever you go, people ask how many children you have. They don't ask how much wealth you have,'' says Sumathy, now 24.

"If I don't have a child now, I'll have to say I don't have anything.''

Tearful at that thought, Sumathy tries to steady her voice. "The doctor assured me I would get pregnant. Whenever I felt sad, she comforted me.''

Doctors like A Kalaichelvi know they must step carefully through this emotional minefield. The surgeon operated on Sumathy in mid-May at the Kilpauk Medical College hospital in Chennai, the state capital. Kilpauk is one of the few public hospitals in India that offers a special unit devoted to the delicate procedure known as recanalization, which involves reconnecting the fallopian tubes. In the past, patients included women who lost children as the result of accidental death or those who wanted more children following remarriage.

Kalaichelvi faces a heavy workload as more bereaved mothers are scheduled to travel to Chennai for help. More than a dozen tsunami survivors have already gone through the operation.

"Psychologically, they feel better after surgery,'' Kalaichelvi observes. But from a medical standpoint, there is no guarantee of success. In many de-veloping countries, tubectomy [also known as tubal ligation] is promoted as a permanent method of birth control. But it is much easier to reverse vasectomies for men than it is to reverse tubectomies for women.

The record at Kilpauk appears promising. In the 732 recanalization cases handled by the hospital unit from 1989 to 2004, 47 percent resulted in healthy births. But an additional 8 percent of pregnancies were ectopic, posing a hazard to the women's health because the fetus developed inside the fallopian tubes. Patients must be strictly monitored, Kalaichelvi cautions.

Yet it remains unclear whether such percentages will hold true for the tsunami survivors. While a women's age, nutrition levels and overall health are important factors, much depends on the quality of the initial tubectomy.

Officials acknowledge that some government doctors operating on poor women have tended to cut too much of the fallopian tubes, making it impossible for women to reverse the procedure. Ironically, this was done to forestall legal claims of method failure. In the past, some Indian women have sought compensation after getting pregnant following a botched tubectomy.

Take the case in India's southwestern state of Kerala, where a privately run spiritual retreat provided funds for nine recanalization patients after the tsu-nami. Of those nine women, only two have a good chance of giving birth again, according to a local gynecologist.

"We want to do adequate counseling,'' says Sheela Rani Chunkath, Secretary of the Health and Family Welfare department in Tamil Nadu. "If they've already lost children, and then put up their hopes and don't give birth, they will be even more traumatized.''

Reproductive health experts stress the importance of such counseling, which they argue has long been lacking in India's overall family planning program. In the drive to reduce the country's growth rate and encourage a two-child norm, medical authorities have often promoted tubectomy without providing adequate explanation of other available birth control methods, including pills, condoms and IUDs, critics maintain. In many villages, the term "family planning'' is virtually synonymous with sterilization. Today, more than two thirds of Indian couples that use contraception are relying on female sterilization.

"The government systems are so entrenched, I don't know whether they will ever make that shift. There should be promotion of choice of contraceptive methods,'' says Saroj Pachauri, regional director for South and East Asia at the New York-based Population Council.

Moreover, Tamil Nadu has been among the most proactive states in conducting tubectomies, even for young women in their 20s. This is a state where 44 percent of women are sterilized, compared to 3 percent who use IUDs and just 1 percent who use pills.

Those choices echo between the thin walls at tsunami relief camps in Nagapattinam, a hard-hit district where 6,065 people died in the tsunami, including 1,776 children. Indira, the wife of a fisherman, recalls that she was feeding her three-year old son and one-year old daughter when the muddy waves crashed overhead. Now, she is childless and awaits the result of her recent recanalization.

"Pray for me to have a child,'' she begs a visitor.

Her neighbor, Amudha, also lost two small children. On the day of the disaster, her four-year-old son was flying a kite on the beach. His body was discovered four days later, underneath the hull of a shattered boat.

But long before the tsunami, Amud-ha had decided against a tubectomy because she and her husband wanted a third child. Instead, she asked for an IUD. After the tsunami, she had it removed. Now, she is six months pregnant.

For some bereaved mothers, the prospect of having more children summons mixed emotions. When Tamil Nadu's flamboyant Chief Minister, J Jayalalithaa, first announced the recanalization policy on television in March, 24-year-old Vanitha was not eager to go to the hospital. Traumatized by the loss of both her toddlers, she resisted her husband's request that she undergo the operation.

"I didn't want any more children,'' she recalls, breaking down in tears. "I felt that my children already died in the tsunami. We worked so hard to raise them. We sacrificed for them. More children will mean more sacrifice.''

But her husband, 29-year old Vasudevan, prevailed. "I want another generation to continue,'' says the autorickshaw driver. "Children bring satisfaction.'' So Vanitha had the operation in early May. Now, she says, her feelings have evolved. "If pregnancy is a possibility, I am very happy. But if I don't get pregnant, that is God's way.''

Stories like Vanitha's raise concern among some Indian activists that the government is compounding social pressures with its high-profile offer to reverse sterilization. In addition to providing the service free at public hospitals, the government promised 25,000 rupees (HK$4,465) in compensation for couples who turned to private clinics.

"The government went into a straightaway, one-point agenda of recanalization,'' complains Beulah Agariah, a program coordinator at Initiatives: Women In Development, a non-government advocacy group based in Chennai. "Women need to be given more space to reflect on the options, whether that option is adoption, recanalization, or to remain childless.''

Is adoption a viable alternative? Apparently not in Nagapattinam, where 120 children crowd into the Annai Sathya Memorial Government Orphanage. Dozens sleep on mats strewn over the cement verandah. More than six months after the tsunami, distraught mothers are still rattling the orphanage gate, clutching photos and looking for sons and daughters who disappeared with the waves.

"They search for their own babies. They would not have the thought of adopting children,'' says Vasantha, a teacher at the institution.

One reason is that formal adoptions are stubbornly unpopular in India. Although some childless couples might take a young member of their extended family into their homes, relatively few are tempted to adopt total strangers. And those who do try to adopt must show medical records to prove they are unable to have children of their own.

For the surviving children and adults, this is still a time of healing. Sumathy says her marriage, too, is on the mend, because of her husband's decision to give up drinking. In addition to hawking fish, she is starting to repair fishing nets and sell vegetables; she wants to save some extra money for the child she yearns to conceive.

She doesn't care if it's a boy or a girl. "Someone to call me `Mother.' That is enough.''